If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Allergy or Adverse drug reaction
- Jatin devraj dedhia (15 November 2006)
-
Documentation of drug allergies
- Malcolm A Broom (3 November 2006)
-
Does the patient truly have, or truly not have, an allergy ?
- Prasanna N Tilakaratna (3 November 2006)
-
Anaphylaxis and Anaesthesia
- M J O'Meara (27 October 2006)
|
|
|||
|
Jatin devraj dedhia, SpR in Anaesthetics
Send letter to journal:
|
Editor, The article by Macpherson and colleagues on anaesthetist's responses to patient's self-reported drug allergies is interesting and would like to share a recent interesting incidence in our ITU patient concerning allergy. I was fast bleeped to come to A&E as there was a 20yrs old male patient who was being escorted by paramedics after having an overdose of Chloral Hydrate.This patient had a witnessed VF arrest in front of the paramedics.He was resusitated and brought to A&E with a GCS of 3/15. He was intubated and transferred to ITU and sedated with morphine and midazolam, later cooled for 24hrs. On questioning the paramedics and his mother in A&E, he seemed to have no known allergies and was otherwise fit and well.After being in ITU for nearly 2 hrs, his partner came to visit him in ITU.She was informed that he is sedated with the above drugs while she was awaiting to see himin the visitors area. She did not react to the above information initialy as she was in a state of shock regarding the entire incident.After about 15 minutes or so, she kept banging the ITU door to tell us that her partner was allergic to Morphine.On further questioning, we were told that he developed a rash and swelling of his face when he had morphine the last time.The patient was on morphine for the last 2 hrs in ITU and there was no adverse reaction this time. We continued to sedate him overnight with morphine and midazolam without any problems.This patient was extubated 48hrs later and was sent to the ward.The patient was later informed that he may have had an adverse drug reaction to morphine, rather than a true allergy to it.This was documented in the notes for future reference. The question here arises that, would some one have given this patient Morphine if he came for an elective surgery? knowing that he had a swelling on his face and developed a rash.Most of us would have probably not given morphine as the history of drug allery was contoversial from the immidiated family members. A poper documentation and getting the exact information to rule out drug allergy or adverse drug information is very important as it save to modify drug treatment and allows us to give the drug which will benefit in the overall patient management. Dr Jatin D. Dedhia, SpR Anaesthesia, University Hospitals of Leicester. Conflict of Interest:None declared |
|||
|
|
|||
|
Malcolm A Broom Glasgow Royal Infirmary
Send letter to journal:
|
Editor, I was interested to read the recent study by MacPherson, Wilcox, Chow and Wang as they investigated and commented on the response to patients reported drug allergies. I believe that there are two main issues regarding documentation of drug allergies which are at least mildy problematic on an almost daily basis. Firstly, I agree that despite many reported "allergies" being non- specific or vague in both their nature and their occurence in time, it is risky to then go ahead and prescribe the stated drug. This may present difficulties, frequently in terms of analgesia. Of course it is sometimes easy to identify side effects such as those who are "allergic" to morphine, which makes them constipated, but more often patients will give the frustrating response that they are "allergic" to morphine, which they were given on an occasion in the past, but cannot remember what happened to them. If the patient is then given morphine and has an anaphylactic reaction, one may appear at best foolish and at worst negligent. However there are also risks attached to changing the mode of analgesia, such as to a regional technique. As ever, a balance of risks will, we hope, present us with the most appropriate course of action. Secondly, I find it an even more frequent occurence, when writing patients drug charts in theatre, that the ward doctor who has clerked the patient and diligently prescribed their medication, has often failed to record any remarks in the allergies section of the chart. It is equally foolish, or negligent, to prescribe onto a drug chart on which there is no documented record of having asked the patient a history of drug allergies. This may be particularly problematic if called upon to anaesthetise a sick or incapacitated inpatient in an emergency. The solution to both of these problems may well be as the authors state, to include a section to document "adverse drug reactions" rather than allergies and to include a more complete description of their nature and occurence. Additionally, nursing staff could be encouraged to request the completion of this section of the drug chart before they dispense any drugs to patients. Sincerely Malcolm Broom Conflict of Interest:None declared |
|||
|
|
|||
|
Prasanna N Tilakaratna, SpR Anaesthetics Royal London Hospital, London, UK
Send letter to journal:
|
Editor, I read with interest the article by Macpherson and colleagues on anaesthetist's responses to patients' self-reported drug allergies [ 1 ] and would like to share two interesting patient reports concerning allergies. The first was a 76 year old patient who came to the operating theater for coronary artery bypass graft surgery and claimed that he was allergic to "water". This was documented on the drug chart and he was even wearing an allergy wristband mentioning "water". On asking how he had managed to survive for so many years without water, he told me that he was only allergic to distilled water and that drinking such water caused him to feel generally unwell, whereas ordinary tap water , which he drank, did not affect him. I ignored this "allergy" since distilled water has much less impurities than tap water and thus was unlikely to be a source of allergy. During the surgery the patient was given plenty of "water" in the form of intravenous and cardiopulmonary bypass pump fluids (e.g. Hartmann’s solution and water for injection) with no apparent harm. The second patient was a 25 year old woman in the labour ward on whom I did a preoperative assessment because she was to have a caesarean section later in the day. When enquiring about allergies , she described how she was "strongly" allergic to penicillin and that she had developed a rash when it was given during her childhood. After assessing her, I remained at a corner of her room to check on some blood results. A few minutes later, the obstetrician entered the room and wanted to prescribe antibiotics to the patient as she had prolonged rupture of membranes (which increased the risk of infection). Before doing so, he discussed some aspects concerning her care and then clearly asked her if she had any allergies. She replied that she had no allergies. Fortunately I overheard the conversation and asked the patient about the penicillin allergy that she mentioned to me only a few minutes earlier. She then recalled the allergy and apologised to the obstetrician for forgetting to mention such a vital thing. The two cases described here are at the opposite ends of the spectrum of allergy reporting. The first patient reported an allergy that was in all probability a nonexistent one whereas the second patient forgot to report an allergy which was probably true and potentially could have had serious clinical implications. Perhaps the lesson here is that one must not always take a patient's self-report of the presence or absence of drug allergies at face value. References 1: MacPherson RD, Willcox C, Chow C, Wang A. Anaesthetist's responses to patients' self-reported drug allergies. Br J Anaesth 2006; 97: 634-639 Conflict of Interest:None declared |
|||
|
|
|||
|
M J O'Meara
Send letter to journal:
|
Editor, I read with interest the article by Macpherson and colleagues on the anaesthetic response to self-reported drug allergies1. The comparison between preoperative self-reported allergy and actual use of these drugs gives a particularly interesting slant to the issue. The ensuing discussion provides a comprehensive review of the published evidence. The use of a dedicated pharmacist in the preoperative clinic adds strength to the methodology in terms of documenting patients’ allergies and the nature of them2,3. However, whilst the findings maybe more accurate, the practical clinical application may be limited. Pharmacists are a potential underutilised source of expertise in this setting and the task of elucidating a drug and drug allergy history is most commonly delegated to junior medical or nursing colleagues - an in-depth allergy assessment may not always be made and the label ‘allergic’ is perpetuated. While this is no excuse, it may be part of the explanation. I would be interested to know if the pharmacists in this study offered any sort of counselling or further testing. In this study, antibiotics, opioids and NSAIDS occurred as the most common individual drug classes to which patients reported allergy. It is interesting, but perhaps not surprising, that patients failed to report allergy to other anaesthetically used drugs, such as muscle relaxants which are reportedly the most common allergy-inducing drugs seen in anaesthetic practice4. Several possible explanations exist. Firstly, the study population may have been too small to pick up such allergies (unlikely). Secondly, these drugs may have appeared in the 122 ‘other’ class. Thirdly, as mentioned by the study authors, patients may be unreliable in recalling history of allergy. Perhaps more likely, we are bad at telling patients and communicating to colleagues of an allergy to such agents. It is interesting to note that the clinicians studied complied in 397/410 cases (96.8%). This is in spite of the fact that patients’ accounts of allergy may be unreliable. The reasons for this complicity require further analysis. ‘Primum non nocere’ should be the motivating factor, i.e., fear of inflicting actual harm to the patient should drive us to avoid giving such drugs. However, there may be other factors. Fear of complaint, disciplinary or legal action if the patient went on to experience an adverse event to such an agent (whether because of true previous allergy or de novo allergy) may also play a role. Having to tell a patient they have been given an agent to which they previously thought they were allergic is at the very least embarrassing. There is also the possibility that ADRs are under-reported once they have occurred5. This would have the effect of artificially raising complicity rates (although not within this study). Finally, the mechanistic nature of an ‘allergic reaction’ is irrelevant to the patient themselves: an unpleasant side- effect experienced is an unpleasant side-effect experienced. Perhaps it is not surprising that patients mislead us in a bid to avoid getting the same drug twice. A change in nomenclature, as suggested by the authors, towards ‘adverse drug reaction’ may allow more clinical leeway in prescribing and better choices to be made in the future. References 1. MAcPherson R, Willcox C, Chow C, Wang A. Anaesthetists response to patients’ self-reported drug allergies. BJA 2006; 97(5): 634-9. 2. Pilzer JD, Burke TG, Mutnick AH. Drug allergy assessment at a university hospital and clinic. American Journal of Health-System Pharmacy 1996; 53(24) :2970-5 3. Bouwmeester MC. Laberge N. Bussieres JF. Lebel D. Bailey B. Harel F. Program to remove incorrect allergy documentation in pediatrics medical records. American Journal of Health-System Pharmacy 2001; 58(18):1722-7. 4. Laxenaire MC, Mertes PM. Anaphylaxis during anaesthesia. Results of a two-year survey in France. British journal of anaesthesia 2001; 87(4): 549 -58. 5. Hazell L, Shakir S. Under-reporting of adverse drug reactions: a systematic review. Drug safety 2006; 29(5): 385-96. M J O’Meara Sheffield Matthew.OMeara@doctors.org.uk Conflict of Interest:None declared |
|||